Abstract Zero-dose children remain a marker of populations unreached by routine immunisation, but national averages can obscure substantial subnational and multidimensional inequities. We analysed the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted between 2015 and 2024, including 170,553 children aged 12–23 months from 77 countries and 1,571 first-level administrative areas. Zero-dose prevalence ranged from 0.22% to 37.21% nationally, and 33 subnational areas had prevalence of at least 50%. Using the Vaccine Economics Research for Sustainability and Equity (VERSE) framework, we found that zero-dose children were consistently concentrated among multidimensionally disadvantaged groups, although the magnitude and drivers of inequity varied across countries. Maternal education, household wealth, geographic region, residence and health insurance were context-specific contributors. Combining burden, subnational distribution and multidimensional inequity can help identify where zero-dose children are concentrated and which barriers should be prioritised to advance equitable immunisation.

BACKGROUND:2024 marked the 50th anniversary of the Expanded Programme on Immunization (EPI), launched by WHO. Despite its crucial role in preventing infectious diseases, EPI's 50-year economic impact has not been systematically evaluated. This study aims to estimate the benefit-cost ratios (BCRs) and incremental cost-effectiveness ratios (ICERs) of EPI at global, regional, and national levels. METHODS:We conducted an economic evaluation of EPI for 14 globally important pathogens with robust long-term data availability: Corynebacterium diphtheriae (diphtheria), Haemophilus influenzae type b, hepatitis B virus (hepatitis B), Japanese encephalitis virus (Japanese encephalitis), measles virus (measles), Neisseria meningitidis group A (meningitis A), Streptococcus pneumoniae, Bordetella pertussis (pertussis), poliovirus (polio), rotavirus, rubella virus (rubella), Clostridium tetani (tetanus), Mycobacterium tuberculosis (tuberculosis), and yellow fever virus (yellow fever) from Jan 1, 1974, to Dec 31, 2024, across 194 WHO member states. We compared costs (procurement, administration, and family additional costs from time spent synthesised from authoritative global databases and systematic literature reviews) and benefits (primarily averted mortality retrieved from published global burden estimates) between observed EPI implementation and a counterfactual scenario of no vaccination, from which BCRs and ICERs were derived. FINDINGS:From 1974 to 2024, the cost of EPI reached US$937 billion (95% CI 699-1187), offset by $15 050 billion (12 609-17 605) in averted productivity losses due to mortality (aggregate BCR 16·06 [95% CI 10·62-25·20]; ICER cost-saving). Immunisation against all 14 pathogens showed favourable economic outcomes. Measles vaccination produced the highest BCR (73·97 [45·78-124·06]), and the ICERs for all vaccines remained below conventional cost-effectiveness thresholds. EPI against 14 pathogens in aggregate achieved cost savings (BCR>1) in all 194 WHO member states. Economic returns varied across six WHO regions and four World Bank income groups, with the Eastern Mediterranean region (BCR 17·22 [11·22-28·67]) and low-income countries (BCR 23·63 [16·87-34·32]) showing the highest BCRs. INTERPRETATION:The 50-year EPI has proven highly cost-effective at global, regional, and national levels, and remains a worthwhile investment. The EPI delivered impactful life-saving benefits and favourable economic returns, especially in high-burden and low-income settings. FUNDING:The National Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Vaccine Impact Modelling Consortium, and the Japan Agency for Medical Research and Development.

Introduction:Varicella is a highly contagious respiratory disease caused by the varicella-zoster virus that predominantly affects children and is prone to outbreaks in congregate settings. This study evaluated the effectiveness of varicella vaccination among children and adolescents aged 0-18 years in Chaoyang District and examined factors associated with infection risk. Methods:A retrospective cohort study was conducted among 551,980 children and adolescents born between 2007 and 2025 using varicella surveillance data from the Chaoyang District Center for Disease Control and Prevention. Incidence rates were calculated, and vaccine effectiveness was estimated using Cox proportional hazards models. Results:Among the 551,980 participants, 9,170 varicella cases were identified. The incidence rate was 20.79 per 1,000 person-years (PY) in the unvaccinated group, 2.28 per 1,000 PY in the one-dose group, and 0.34 per 1,000 PY in the two-dose group. Increasing vaccine dose number was significantly associated with a lower risk of infection. The cumulative incidence of varicella was lowest and most stable in the two-dose group during follow-up. Vaccine effectiveness (VE) was 96.8% [95% confidence interval (CI): 95.7%, 97.6%] for one-dose vaccination and 98.2% (95% CI: 97.9%, 98.5%) for two-dose vaccination. Males accounted for 56.2% of cases and had a slightly higher infection risk than females. Conclusion:Two doses of varicella vaccine provided strong protection against varicella. These findings support efforts to increase two-dose vaccination coverage and optimize varicella immunization schedules.

Background:Despite the universal availability of free preconception care (PCC) in China, substantial disparities in utilization persist. It remains unclear how much of this reflects structural barriers versus individual shortfalls, and clarifying this balance is critical for designing equitable, accountable maternal health policy. Methods:We conducted a multi-center cross-sectional survey across ten medical facilities in China from July 1, 2023, to July 1, 2024, including 8,866 pregnant women. Guided by the Equality of Opportunity framework, we applied logistic regression to assess PCC factors and three machine learning models to assess factors' contributions of PCC utilization. Shapley Additive Explanations (SHAP) decomposition quantified the contribution of individual-level "effort" versus structural "circumstance" factors. Subgroup analyses explored heterogeneity by education level, urban-rural residents, whether or not the annual PCC promotion was accepted at local MCH institutions, and pregnancy intention status. Results:Overall PCC uptake was 42.4%, with disparities strongly associated with individual-level factors as well as structural determinants. Effort-related variables, particularly pregnancy intention and knowledge of PCC, were the strongest predictors across all models, accounting for 74.1-93.6% of explained variation. However, circumstance factors, including annual PCC promotion at local maternal and child health institutions, remained influential, especially among vulnerable subgroups such as women with unplanned pregnancies, for whom structural factors explained nearly half of the disparity. Conclusion:Our findings reveal that even in systems offering universal coverage, access to PCC remains stratified by structural opportunity. Although individual-level knowledge and intention are key levers, they are themselves shaped by broader social conditions. Addressing PCC inequality thus requires integrated strategies that promote both individual empowerment and systemic equity.

Objectives: To investigate associations between varicella vaccination and self-reported contact history with varicella or herpes zoster among clinically diagnosed varicella cases in Chaoyang District, Beijing, China. Methods: A retrospective observational study was conducted among 4441 clinically diagnosed varicella cases reported from 2017 to 2025. Multivariable logistic regression examined associations between vaccination status, number of doses, time since vaccination, and reported contact history with varicella and/or herpes zoster, adjusting for age, sex, and year of diagnosis. Results: Vaccinated cases had significantly higher odds of reporting contact with varicella or zoster compared with unvaccinated cases (OR = 1.34, 95% CI: 1.14-1.58). Both 1-dose and 2-dose recipients showed similar associations. A gradient of increasing odds was observed with longer time since vaccination, reaching OR = 3.17 (95% CI: 1.39-7.22) for 10 or more years since last dose. Associations were primarily driven by reported varicella contact rather than herpes zoster contact. Sensitivity analysis confirmed robustness of findings. Conclusions: Varicella vaccination was positively associated with reporting an identifiable exposure source. Vaccination status may influence completeness of exposure ascertainment in varicella surveillance and should be considered when interpreting contact tracing data.

Importance:Electronic cigarettes (e-cigarettes) are appealing to adolescents, but sale of e-cigarettes to individuals younger than 18 years is prohibited in China. The effect of school uniforms on e-cigarette sales to adolescents has not been explored. Objective:To study e-cigarette sales to adolescents wearing school uniforms compared with those wearing casual attire. Design, Setting, and Participants:This 2-arm randomized clinical trial involved adolescent mystery shoppers wearing school uniforms or casual attire who attempted to purchase e-cigarettes. The trial was conducted across 36 major metropolitan areas in China from July 29 to September 3, 2023. Adolescent buyers aged 18 to 19 years were randomly assigned to wear 1 of the 2 attire types. A 1:1 matching of e-cigarette and cigarette stores was also performed. Intervention:Adolescent buyers attempting to purchase e-cigarettes while wearing school uniforms were the intervention group, and those in casual attire served as the control group. Main Outcomes and Measures:The primary outcome was successful purchase of e-cigarettes. Secondary outcomes assessed whether sellers verbally inquired about the buyer's age, requested an identification (ID) card for age verification, or dissuaded the buyers from using e-cigarettes. Multivariable logistic regression models identified factors associated with outcomes by attire type, adjusted for buyer, seller, and store characteristics. Results:The final analytical sample included 1089 visits to e-cigarette stores (543 by adolescents in school uniforms and 546 by those in casual attire) and 1059 visits to cigarette stores. Of the e-cigarette stores visited, 85.4% (95% CI, 80.3%-89.4%) posted external advertising, 39.4% (95% CI, 35.9%-43.0%) were located in shopping malls, 90.8% (95% CI, 87.7%-93.2%) displayed age-of-sale signs, and only 15.0% (95% CI, 9.7%-22.5%) exhibited health warnings specifically for e-cigarettes. The overall success rate of adolescents purchasing e-cigarettes without age verification was 78.3% (95% CI, 75.8%-80.6%), significantly lower than the 94.5% (95% CI, 91.3%-96.6%) success rate for purchasing cigarettes without age verification. Adolescents wearing school uniforms had significantly lower odds of successfully purchasing e-cigarettes (adjusted odds ratio [AOR], 0.39; 95% CI, 0.23-0.66) than those in casual attire and were more likely to be asked about their age (AOR, 9.18; 95% CI, 6.46-13.06), requested to show an ID card (AOR, 6.68; 95% CI, 4.53-9.87), and dissuaded from using e-cigarettes (AOR, 1.79; 95% CI, 1.30-2.47). Additionally, when sellers requested ID cards, the probability of successful e-cigarette purchases was significantly lower than when they did not (AOR, 0.02; 95% CI, 0.01-0.03). Conclusions and Relevance:In this randomized clinical trial of e-cigarette sales, e-cigarettes remained widely sold to adolescents without age verification in China, but wearing a school uniform appeared to reduce adolescents' ability to purchase e-cigarettes. Trial Registration:ClinicalTrials.gov Identifier: NCT05962411.

Background: Childhood immunization is one of the most effective public health strategies for reducing morbidity and mortality from vaccine-preventable diseases. Although overall vaccination coverage in the United States remains high, disparities persist across socioeconomic and healthcare access groups. Understanding these disparities is particularly important in the post-COVID-19 era, when increased vaccine hesitancy may threaten progress in maintaining equitable coverage. Materials and Methods: We analyzed data from the National Immunization Survey–Child (NIS-Child), focusing on U.S. children aged 19–35 months in 2023, corresponding to cohorts reaching this age during or after the COVID-19 pandemic. The primary outcome was receipt of the up-to-date combined 7-vaccine series (4:3:1:3:3:1:3: ≥4 doses of DTaP, ≥3 doses of polio, ≥1 dose of measles-containing vaccine, full Hib series, ≥3 doses of hepatitis B, ≥1 dose of varicella, and ≥3 doses of PCV). Logistic regression models were used to estimate associations between vaccination coverage and key explanatory variables: household income-to-poverty ratio, maternal education, health insurance type, and provider facility type, controlling for demographic and regional covariates. Disparities were quantified using concentration indices (CIs). Results: Among children in the analytic sample, overall coverage for the 7-vaccine series was only 78.5%. Nonetheless, disparities were evident. Children from households with lower income-to-poverty ratios (<1 × FPL: OR = 0.44, 95% CI = 0.37–0.53; 100–200%: OR = 0.66, 95% CI = 0.56–0.79), those covered by Medicaid (OR = 0.54, 95% CI = 0.45–0.64), other insurance (OR = 0.48, 95% CI = 0.37–0.61), or uninsured (OR = 0.27, 95% CI = 0.18–0.42), and those whose mothers had lower educational attainment (<12 years: OR = 0.35, 95% CI = 0.28–0.44) had significantly lower odds of being up-to-date. Similar associations were observed across specific vaccines. Unadjusted CIs for income-to-poverty ratio (0.04, p < 0.01), maternal education (0.04, p < 0.01), health insurance (0.03, p < 0.01), and provider type (0.03, p < 0.01) decreased but remained statistically significant after adjustment (0.02, 0.02, 0.01, and 0.02, respectively; all p < 0.01). No significant disparities were found by census region or race/ethnicity. Discussion: Despite relatively high overall vaccination coverage among U.S. children born during and after the COVID-19 pandemic, disparities by socioeconomic and healthcare access factors persisted. However, the absolute magnitude of these disparities was very small (concentration indices ≤ 0.04). These findings suggest that while inequities remain statistically measurable, their scale is limited in absolute terms. Targeted efforts to address income, insurance, maternal education, and provider-related barriers will be important to sustain equitable immunization coverage in the post-pandemic era.

Background While research in multiple countries confirms that primary care functional features significantly improve patient health, China's primary care system differs markedly due to unique structural and contextual factors. This study aims to measure and explore the functional features experienced by patients received family doctor contract service in the past year, evaluating the impacts and pathways of these primary care features on health outcomes. Methods We employed a mixed-methods explanatory sequential design. In the quantitative phase, we randomly selected 2118 residents from 12 primary care institutions. The intensity of functional features was assessed using the Person-Centered Primary Care Measure (PCPCM), and their association with levels of EuroQol Visual Analogue Scale (EQ VAS) was evaluated through multilevel modelling. In the qualitative phase, a qualitative description approach was used, conducting 24 focus groups with a total of 85 patients to gather in-depth information about their experiences with functional features and perceived health impacts. Finally, the quantitative and qualitative data were integrated using meta-synthesis and joint display methods to validate, interpret, and expand the results. Results The average PCPCM score was 3.65, with subdomain scores ranging from 3.39 to 3.83. Qualitative findings confirmed the quantitative results regarding the intensity and manifestation of features like accessibility, coordination, and relationship-building. However, discrepancies were noted in features such as comprehensiveness, integration, and family and community context. Additionally, two new functional features, 'being appreciated' and 'being cared for,' were identified. The quantitative results also showed that higher PCPCM scores were positively associated with EQ VAS levels (odds ratio (OR) = 1.18; 95% confidence interval (CI) = 1.03-1.35, P < 0.001). Furthermore, qualitative results revealed six key pathways supporting the beneficial effects of local primary care functional features on health maintenance and improvement. Conclusions This study demonstrates high functional scores for Shanghai's family doctor services and highlights a positive association between primary care functionality and population health. These features and their health benefits are deeply shaped by the local social and health care context. This confirms the progress of Shanghai's primary care development and underscores the need for further exploration of primary care functional features across China, along with the development of tools tailored to local conditions to better measure and improve primary care quality and health outcomes.

BACKGROUND:Seasonal influenza illness and acute respiratory infections can impose a substantial economic burden in low- and middle-income countries (LMICs). We assessed the cost of influenza illness and acute respiratory infections across household income strata. METHODS:We conducted a secondary analysis of data from a prior systematic review of costs of influenza and other respiratory illnesses in LMICs and contacted authors to obtain data on cost of illness (COI) for laboratory-confirmed influenza-like illness and acute respiratory infection. We calculated the COI by household income strata and calculated the out-of-pocket (OOP) cost as a proportion of household income. RESULTS:We included 11 studies representing 11 LMICs. OOP expenses, as a proportion of annual household income, were highest among the lowest income quintile in 10 of 11 studies: in 4/4 studies among the general population, in 6/7 studies among children, 2/2 studies among older adults, and in the sole study for adults with chronic medical conditions. COI was generally higher for hospitalizations compared with outpatient illnesses; median OOP costs for hospitalizations exceeded 10% of annual household income among the general population and children in Kenya, as well as for older adults and adults with chronic medical conditions in China. CONCLUSIONS:The findings indicate that influenza and acute respiratory infections pose a considerable economic burden, particularly from hospitalizations, on the lowest income households in LMICs. Future evaluations could investigate specific drivers of COI in low-income household and identify interventions that may address these, including exploring household coping mechanisms. Cost-effectiveness analyses could incorporate health inequity analyses, in pursuit of health equity.

Background Respiratory syncytial virus (RSV) causes substantial acute lower respiratory infections (ALRI), particularly during infants’ first RSV season. This study evaluated the impact of a new long-acting monoclonal antibody, nirsevimab, on Chinese infants.Research design and methods A monthly decision-analytic model assessed nirsevimab’s impact for the 2024 birth cohort, incorporating domestic RSV-ALRI parameters. Outcomes included RSV-ALRI cases, hospitalization involving intensive care unit admission and mechanical ventilators use, in-hospital deaths and quality-adjusted life years (QALYs).Results Without intervention, a total of 873 035 RSV-ALRI cases (269 067 hospitalized), 2 125 deaths, 74 422 QALY loss and $998 million costs were estimated, where higher-risk infants (5.23% of the cohort) accounted for 8.83% of inpatient cases, 12.23% of deaths and 9.87% of costs. With 20% coverage for higher-risk and 10% for healthy term infants, nirsevimab could prevent 61 094 RSV-ALRI cases (19 905 hospitalized), 168 deaths and 5 808 QALY loss, saving $77 million. Tripling the coverage could avert 183 282 RSV-ALRI cases (59 713 hospitalized), 506 deaths and 17 425 QALY loss, saving $231 million.Conclusions Nirsevimab introduction could effectively mitigate RSV-ALRI burden in Chinese infants, and enhanced coverage is recommended to maximize the public health benefits.

Objectives:Cervical cancer remains a significant global health concern, particularly in less developed regions. This study aims to assess the global, regional, and national burden of cervical cancer from 1991 to 2021. Methods:This study synthesizes data from the Global Burden of Disease (GBD) Study 2021, WHO health expenditure databases, and published cost estimates to comprehensively assess the epidemiological and economic burden of cervical cancer from 1991 to 2021. We analyzed age-standardized rates (ASRs) of prevalence (ASPR), incidence (ASIR), mortality (ASMR), and disability-adjusted life years (ASDR) using GBD 2021 data. Temporal trends were quantified via Joinpoint regression-derived average annual percentage changes (AAPCs). Direct medical costs were estimated by integrating GBD incidence data, WHO per-capita health expenditure growth rates, and published treatment costs (2015), reported in both undiscounted and 3% discounted 2021 USD. Results:In 2021, globally, there were 3,385,000 prevalent cases, 667,000 incident cases, 297,000 deaths, and 7,440,000 DALYs attributed to cervical cancer. Sub-Saharan Africa bore the highest burden, while 12 countries in North Africa and Middle East reported incidence rates below 4 per 100,000. From 1991 to 2021, AAPCs in ASPR, ASIR, ASMR, and ASDR were 0.08%, -0.52%, -1.22%, and -1.21%, respectively. Despite the 2018 elimination initiative, overall incidence and mortality trends showed minimal change. Age-specific incidence notably decreased in individuals over 70, with slower mortality declines in higher age groups. AAPCs positively correlated with 1991 baseline rates and negatively with 2021 socio-demographic index (SDI). Over the same period, the global cumulative direct medical cost of cervical cancer was estimated at USD 9.26 billion (95% UI: 7.95-10.70) without discounting, and USD 7.21 billion (95% UI: 6.14-8.40) when discounted to 2021. Conclusion:The global cervical cancer prevalence continues to rise, with no country achieving the elimination threshold. High incidence is concentrating in younger ages, while high mortality is shifting to older ages. Sub-Saharan Africa requires targeted interventions to address its disproportionate burden. The substantial economic burden reinforces the urgency for early prevention, equitable treatment access, and sustained health investment.

>Lung cancer, the leading cause of cancer deaths worldwide and in China, has a 19.7% five-year survival rate due to terminal-stage diagnosis [1-3] .Although low-dose computed tomography（CT） screening can reduce mortality, high false positive rates can create economic and psychological burdens.

Studies on vaccine economic evaluation in China's mainland have grown rapidly. To support the improvements regarding how the vaccine economic evaluation studies are designed and conducted, and to provide an overview on the cost-effectiveness levels of different vaccines or vaccination strategies in China setting, this systematic review comprehensively collected and evaluated vaccines economic evaluation studies in China's mainland and descriptively synthesize the cost effectiveness findings reported by those high-quality studies. A search of nine electronic databases was conducted in July 2023 and Joanna Briggs Institute (JBI) criteria was used to assess the methodological quality of the included studies. The cost and effectiveness/utility/benefits and costs outcomes of included studies were manifested in a decision matrix following the JBI guideline on presenting outcomes for an economic evaluation. A total of 133 studies were included and evaluated 20 types of vaccines. The major comparisons were whether to be vaccinated and whether to be included in national immunization program. The evaluation results of 36 studies being evaluated as high-quality were positioned in decision matrix, and it is found that except for the evaluation for human papillomavirus vaccine (HPV), the conclusions of different included studies about the same vaccination strategies were all in the same quadrant. The majority of vaccination strategies showed the incremental cost-effectiveness ratio (ICER) were lower than gross domestic product (GDP) per capita or three times of GDP per capita. Based on descriptive comparison of evaluation results reported by high quality studies, the tentative recommendations for expanding vaccine coverage include the vaccination of hepatitis A and E, domestic HPV-2, pneumococcal conjugate vaccine-13 (PCV-13), influenza, and Haemophilus influenzae type B (Hib). The methodology quality assessment in this systematic review suggested that the quality of economic evaluation studies on vaccination strategies in China is dependent on more high-quality primary studies in China setting, including efficacy or effectiveness of vaccine, relevant disease epidemiology and disease burden studies.

Objective: This study systematically reviews health economic evaluations of influenza vaccines in China and synthesizes the evidence on different vaccine categories. Methods: We searched databases, including the China Hospital Knowledge Database, Wanfang, PubMed, Web of Science, and Embase, for studies on the health economics of influenza vaccines in China from 2015 to 2024. Studies were selected based on predefined criteria, and relevant data were extracted for analysis. The research utilized a parameter, ICER/threshold, defined as the ICER divided by the GDP per capita, to compare the results of cost-effectiveness analysis (CEA) studies. Results: A total of 1743 articles were identified, of which 25 met the inclusion criteria for full-text review. These included 19 Chinese studies and 6 English studies. Study populations were predominantly older adults (52.0%), followed by children, adolescents, people with chronic disease, and pregnant women. Vaccination strategies included trivalent inactivated influenza vaccine (TIV), quadrivalent inactivated influenza vaccine (QIV), trivalent live-attenuated influenza vaccine (LAIV), and non-vaccination groups. For TIV, 94.7% reported positive cost-effectiveness or cost-benefit results, with 21.1% identifying it as the most dominant strategy. For QIV, six studies compared it with a non-vaccinated group, and five (83.3%) reported favorable economic results. The study on LAIV showed cost-effectiveness compared to no vaccination, but not compared to QIV. The ICER threshold for TIV is the most favorable, and the population that exhibits the highest cost-effectiveness and benefit from vaccination is those people with underlying health conditions. Conclusions: TIV vaccination is often cost-effective, especially for people with chronic diseases, children, and older adults. Prioritizing TIV vaccination for those people with chronic diseases is recommended.

Background: The COVID-19 pandemic led to an unprecedented global health and economic crisis, and vaccination emerged as a critical intervention to control the spread of the virus and mitigate its impact on health systems and economies. Despite the rapid development and deployment of vaccines, the financial commitments required for these vaccination programs are substantial, necessitating a comprehensive understanding of the associated costs to inform future public health strategies and resource allocation. Method: This analysis estimates the global, regional, and national economic costs of COVID-19 vaccination across 234 countries and regions in the period 2020–2023, consisting of vaccine procurement costs and administration costs. Result: As of 31 December 2023, the global costs of COVID-19 vaccination programs were estimated at USD 246.2 billion, with vaccine procurement accounting for approximately USD 140.2 billion and administration costs totaling USD 96.4 billion. Globally, a cumulative total of 136.9 billion doses of COVID-19 vaccines had been administered. Factoring in an estimated wastage rate of 10%, it is projected that approximately 150.6 billion doses were used. On a global scale, the average number of vaccine doses administered per capita was estimated at 1.73. The mean cost per capita was USD 17.70 (95% CI: USD 15.84–19.56) for vaccine procurement and USD 12.16 (95% CI: USD 10.29–14.02) for administration, resulting in a total average cost of USD 29.85 (95% CI: USD 26.33–33.37) per capita. Significant disparities in costs were observed across income groups and regions. High-income countries incurred a notably higher average cost per capita of USD 76.90 (95% CI: USD 72.38–81.41) in contrast to low-income countries, where the per capita cost was USD 7.20 (95% CI: USD 5.38–9.02). For middle-income countries, the average per capita costs were USD 15.02 (95% CI: USD 10.64–19.40) in lower-middle-income countries and USD 28.21 (95% CI: USD 23.60–32.83) in upper-middle-income countries. Regionally, the Americas (AMR) reported the highest total cost at USD 70.8 billion, with an average per capita cost of USD 65.23 (95% CI: USD 56.18–74.28). The Western Pacific Region (WPR) followed with a total cost of USD 63.9 billion and an average per capita cost of USD 31.93 (95% CI: USD 20.35–43.51). Conversely, the African Region (AFR) had the lowest total spending at USD 10.8 billion and a per capita cost of USD 8.85 (95% CI: USD 5.34–12.37), reflecting both lower vaccine procurement and administration costs. The European Region (EUR) recorded a high average per capita cost of USD 53.36 (95% CI: USD 46.79–59.94), with procurement costs at USD 31.28 (95% CI: USD 27.41–35.14) and administration costs of USD 22.09 (95% CI: USD 19.31–24.87). Conclusions: The global rollout of COVID-19 vaccination revealed substantial variation in cost structures across income groups. Procurement costs imposed greater burdens on low- and lower-middle-income countries, whereas delivery and administration costs dominated in higher-income settings. These disparities highlight persistent fiscal inequities and emphasize the need for stronger international coordination and cost transparency to enhance equity, efficiency, and preparedness in future vaccination efforts.

Health economic evaluations of childhood obesity interventions are critical for determining the economic feasibility, sustainability, and scalability, thereby informing their policy relevance. This study conducted a comprehensive economic evaluation of a multi-component, App-assisted obesity prevention intervention—compared with usual care—to assess its value for widespread implementation. The Diet, Exercise, and Cardiovascular Health–Children (DECIDE-Children) intervention was a cluster randomized clinical trial involving 24 schools across three socioeconomically distinct regions in China, targeting children aged 8 to 10 years. Schools were randomly assigned (1:1) to either the intervention group or the control group (usual health education). The intervention included school, family, and student components supported by a mobile application for health education, behavior monitoring, weight management, and feedback. A societal perspective was adopted for the economic evaluation. Total costs included direct financial expenditures (e.g., materials, equipment) and labor costs. Incremental cost-effectiveness ratios (ICERs) were calculated for primary obesity-related outcome measure. Using an obesity progression model, we estimated the number of adult obesity cases prevented up to age 65, quality-adjusted life years (QALYs) gained, incremental cost-utility ratio (ICUR), cost–benefit ratio (CBR), and net benefits. The total cost of implementing the 1-year intervention was 13,769.74 USD, averaging 19.53 USD per student in the intervention group. Compared with usual care, the ICERs were as follows: 42.46 USD (95

BACKGROUND:The Expanded Program on Immunization (EPI), initiated by WHO in 1974, is a cornerstone of public health. China's EPI covers more than a sixth of the world's population and includes eight routine vaccines with high coverage rates. This study aimed to estimate health and economic impacts of China's EPI over the past 50 years (1974-2024). METHODS:This study mathematically modelled the impact of all eight routine vaccines in China's EPI against eight pathogens (measles, pertussis, hepatitis B, tuberculosis, hepatitis A, Japanese encephalitis, meningitis A, and poliomyelitis) based on data availability and their substantial disease burden, particularly accounting for non-linearities in vaccine impact. Health and economic outcomes were determined using mathematical models between a counterfactual scenario without vaccination (vaccine coverage set to zero) and the current vaccination scenario (routine vaccination scheduled at age 0-6 years), based on calendar year and birth cohort approaches. The health impact of China's EPI from 1974 to 2024 was measured in the number of cases, deaths, and disability-adjusted life-years (DALYs) averted. FINDINGS:We estimated that China's EPI averted 703·02 million cases (95% credible interval 699·51-722·80) and 2·48 million deaths (2·14-2·97) in 1974-2024 based on the calendar year approach, equivalent to averting an estimated 160·22 million DALYs (145·05-196·99). Using the birth cohort approach, we predicted 707·41 million cases (703·93-727·03) and 7·01 million deaths (6·95-7·87) averted over the lifetime, corresponding to 279·02 million DALYs (265·78-316·12). From a societal perspective, the aggregated cost of vaccination was estimated to be US$124·06 billion (120·49-127·49), although the benefits amounted to $2417·85 billion (2359·38-2710·35). China's EPI yielded an aggregate benefit-cost ratio of 19·48 (18·82-22·08) from the societal perspective and 8·02 (7·64-8·80) from the provider's perspective. INTERPRETATION:China's EPI has shown remarkable health and economic achievements, contributing to worldwide EPI success in the past 50 years. Further investment in EPI is warranted to sustain coverage and expand vaccine inclusion in China and globally. FUNDING:Beijing Natural Science Foundation. TRANSLATION:For the Chinese translation of the abstract see Supplementary Materials section.

Electronic cigarettes (e-cigarettes) are appealing to adolescents, but sale of e-cigarettes to individuals younger than 18 years is prohibited in China. The effect of school uniforms on e-cigarette sales to adolescents has not been explored. To study e-cigarette sales to adolescents wearing school uniforms compared with those wearing casual attire. This 2-arm randomized clinical trial involved adolescent mystery shoppers wearing school uniforms or casual attire who attempted to purchase e-cigarettes. The trial was conducted across 36 major metropolitan areas in China from July 29 to September 3, 2023. Adolescent buyers aged 18 to 19 years were randomly assigned to wear 1 of the 2 attire types. A 1:1 matching of e-cigarette and cigarette stores was also performed. Adolescent buyers attempting to purchase e-cigarettes while wearing school uniforms were the intervention group, and those in casual attire served as the control group. The primary outcome was successful purchase of e-cigarettes. Secondary outcomes assessed whether sellers verbally inquired about the buyer’s age, requested an identification (ID) card for age verification, or dissuaded the buyers from using e-cigarettes. Multivariable logistic regression models identified factors associated with outcomes by attire type, adjusted for buyer, seller, and store characteristics. The final analytical sample included 1089 visits to e-cigarette stores (543 by adolescents in school uniforms and 546 by those in casual attire) and 1059 visits to cigarette stores. Of the e-cigarette stores visited, 85.4% (95% CI, 80.3%-89.4%) posted external advertising, 39.4% (95% CI, 35.9%-43.0%) were located in shopping malls, 90.8% (95% CI, 87.7%-93.2%) displayed age-of-sale signs, and only 15.0% (95% CI, 9.7%-22.5%) exhibited health warnings specifically for e-cigarettes. The overall success rate of adolescents purchasing e-cigarettes without age verification was 78.3% (95% CI, 75.8%-80.6%), significantly lower than the 94.5% (95% CI, 91.3%-96.6%) success rate for purchasing cigarettes without age verification. Adolescents wearing school uniforms had significantly lower odds of successfully purchasing e-cigarettes (adjusted odds ratio [AOR], 0.39; 95% CI, 0.23-0.66) than those in casual attire and were more likely to be asked about their age (AOR, 9.18; 95% CI, 6.46-13.06), requested to show an ID card (AOR, 6.68; 95% CI, 4.53-9.87), and dissuaded from using e-cigarettes (AOR, 1.79; 95% CI, 1.30-2.47). Additionally, when sellers requested ID cards, the probability of successful e-cigarette purchases was significantly lower than when they did not (AOR, 0.02; 95% CI, 0.01-0.03). In this randomized clinical trial of e-cigarette sales, e-cigarettes remained widely sold to adolescents without age verification in China, but wearing a school uniform appeared to reduce adolescents’ ability to purchase e-cigarettes. ClinicalTrials.gov Identifier: NCT05962411

Objective To evaluate the effectiveness, patient experience, and cost-efficiency of primary care versus hospital care for middle-aged and elderly patients with chronic diseases in China, in the context of achieving the triple aim of healthcare: improving population health, reducing per capita costs, and enhancing patient satisfaction.Methods A longitudinal cohort analysis using data from the China Health and Retirement Longitudinal Study (CHARLS) spanning the years 2011, 2013, 2015, and 2018.The study included participants aged 45 and older from 450 communities across mainland China, specifically targeting those with chronic diseases. Individuals without chronic conditions or with incomplete data were excluded.Results The analysis encompassed 50,800 subjects. Those who visited hospitals for outpatient treatment—mainly urban residents with higher education and income levels, and with comprehensive insurance coverage—demonstrated poorer health outcomes (OR = 1.06, 95%CI 1.02–1.10, p = 0.002) and higher medical expenses (OR = 1.99, 95% CI 1.93–2.06, p < 0.001) compared to those who utilized primary care facilities. No significant difference was observed in satisfaction levels between the two groups (OR = 0.99, 95% CI 0.92–1.07, p = 0.85).Conclusions This study indicates that for patients over 45 with chronic diseases, China's primary care can achieve health outcomes comparable to or better than large hospitals, at significantly lower costs. Despite some data limitations, it highlights the effectiveness of primary care in improving health for socioeconomically disadvantaged groups, advocating for more government investment and policy support to enhance primary care's affordability and functionality.